0:01

Now, I would suggest in fact that there are

0:05

eight varieties, at least these are the ones

0:08

that now have been described in the literature.

0:10

Eight major varieties of the pathologic morphology

0:15

of the labral lesion occurring with slap.

0:19

You can see them here.

0:20

Some are seen in fact with degenerative changes,

0:23

others are seen associated with injury.

0:27

And we're gonna talk about most, but not all of these.

0:31

Now, when you are dealing with superior labral tears

0:34

or detachment, there is a likelihood

0:37

that you may see a paralabral gangly in cyst.

0:41

And those cysts are a variable size, some are large,

0:46

and if they are large, they can erode the bone, the scapula,

0:50

and here's what one would look like,

0:52

and the spinal glenoid notch with extensive erosion

0:56

involving the posterior glenoid in the area

0:59

of the spinal glenoid notch.

1:02

In addition, when they're large,

1:04

they may affect the suprascapular nerve,

1:07

which supplies both the supraspinatus

1:09

and in infraspinatus muscles, depending upon their location.

1:13

That is the ganglia cyst.

1:16

Both muscles may be involved or as shown here.

1:19

Those in the spinal glenoid notch may lead to denervation

1:23

of the infraspinatus muscle alone.

1:27

But sometimes these ganglion cysts are small.

1:30

Something to remember is these may not fill

1:34

with contrast material.

1:36

So that is why if you do arthrography,

1:38

you need fluid sensitive sequences to look for them.

1:42

You'll see them on the fluid sensitive sequence.

1:48

So these are the par label ganglia cyst.

1:52

Now let's look at the birth of slap lesions.

1:56

It's the article by Steven Snyder,

1:59

an orthopedic surgeon in Southern California in 1990

2:03

that described lesions of the superior labrum.

2:06

Now, he was not the first person to describe such lesions,

2:10

but he was the first person to use the term slap

2:15

superior labral, antral and posterior lesions.

2:18

And that's a very patchy name.

2:20

And so it's not surprising that it caught on.

2:25

He was also smart.

2:27

If you want things to sound important,

2:30

you use Roman numerals.

2:32

And so he used Roman numerals to describe these lesions.

2:36

I mean, they're used for always big events like

2:39

and things like this.

2:41

So he was very smart.

2:43

And so there are Roman numerals applied to all

2:46

of the slap lesions.

2:48

Steven Snyder and his colleagues described four of them,

2:51

and we'll be going through them in this lecture.

2:54

But I wanna emphasize at this point that the one,

2:59

the slap, Roman numeral one

3:01

that he described was a degenerative lesion.

3:05

And because he included that, a lot of people believe

3:09

that there is an over-diagnosis of slap lesions in, uh,

3:14

studies of the glen numeral joint

3:16

and that arthroscopy as well, that

3:19

that should not have been included

3:21

in the original description.

3:24

The DI inclusion of these lesions, which lead

3:27

to fraying irregularity

3:28

and tearing typically of the upper quadrant,

3:32

the superior portion of the labrum, uh, means

3:36

I think we have an overuse

3:38

of the designation slap at the current time.

3:41

So I can tell you in my practice,

3:43

I rarely call a SLAP lesion in someone over the age

3:48

of 30 years, and I never label it a SLAP lesion,

3:52

particularly if it looks degenerative in nature.

3:56

Now, there are other problems with these descriptions

3:58

that we're gonna get into, but I'll mention one.

4:02

He talked about detachments in certain areas.

4:06

What happens if you have a tear in

4:08

that same area but not a detachment?

4:10

Should that be called a SLAP lesion as well?

4:13

Those sorts of things

4:16

and problems with terminology do arise.

4:21

It was the article by MapIT in 1995, along

4:26

with his colleagues that expanded the number of

4:29

SLAP Roman numeral lesions.

4:32

Those increased to eight or nine

4:35

and through the meetings at the RSNA, yes, radiologists are

4:39

to blame for part of this.

4:41

Slap 10 lesions were also identified.

4:44

Last time I looked, we haven't gotten up

4:47

to anything higher than 10.

4:49

The Roman numerals get a little bit more complicated if we

4:52

go higher than that, uh, number

4:55

do the Roman numerals matter?

4:57

Absolutely not many orthopedic surgeons

5:01

do not know these numerals

5:04

or only know slaps one through four.

5:07

And there's controversy regarding the treatment of each

5:11

of the many patterns.

5:13

Conservative, uh, neglect, debridement, resection,

5:16

even tenodesis is becoming more popular in the treatment

5:21

of these slap lesions.

5:23

Now, there are, um, clinical findings

5:26

that are associated with them.

5:27

And the left hand part of this slide, I'm showing you some

5:30

of those clinical, uh, findings.

5:32

And there are a number of clinical tests.

5:35

I'm showing you one of them here,

5:36

the O'Brien test on your right.

5:39

But there's a spree, a speed test, and a ysy test as well.

5:44

Now, most of the descriptions in our literature

5:47

and in the orthopedic literature talk about

5:51

superior labral lesions

5:53

or lesions in continuity where there are

5:56

Superior labral lesions and lesions in other quadrants.

6:00

On the right, I show you superior

6:03

and anterior labral lesions.

6:04

And most of the time in the descriptions

6:07

they are in continuity.

6:10

But I don't think they always begin that way.

6:12

Indeed, perhaps they begin separately, for example, superior

6:17

and perhaps they begin separately beginning anteriorly.

6:21

And over time what occurs is those particular

6:25

lesions collide.

6:27

There are very few longitudinal studies that tell us

6:30

where these expanded slap lesions begin,

6:35

where they go do they begin as continuous lesions

6:40

or as separate lesions.

6:42

And I'm not gonna be able to answer that in this, uh,

6:45

lecture.